Employee code

(Mandatory)
FORM 2 (Revisedl
(For Unexempted /Exempted Establishments)
NOMINATION AND DECLARATION FORM
(Declaration and Nomination Form under the Employees' Provident Funds and Employees' Pension Scheme)

(Paragraphs 33 & Gl (1) oflhe Employecs' Provident Fsnds Schemq 1952 and paragraRh 18 ofthe Employees' Pension
Scheme,1995)

1 ilame (in Block Letters) : LALT-T KUryRR sEN

2 Fathe/s/Husband's lUame , t<nLyaN PRAsnD
3 Date of birth
: 6f-oB-135{
4 Sex /t't aLg
5 Marital Status A4 ARRaED
6 Account No. 1a"r/wes lMum6er)

7 Address (cpsi[entiaQ permanent g &r4- PunA Nqrk),t' Ag^!4 i, Afvtar

Temporary m) tu3
b) ,GqAPuTq (\c A-lh Slujquqr(!
m
PARr A (EPF)Li
I hereby nominate the person(s)/cancel the nomination made by me previously and nominate, the person(s) mentioned
below to receive the amount standing to my credit in the Employees' Provident Fund, in the event of my death:

Name and Address of the nomined nominees lf

Nominee's Total amount the nominee is a
relationship or share of minor, name and
with the accumulatims relationship and
member in Provident address of the
Fund to be guardian who may
paid to each receiue the am(xtnt
nominee (7o) during the minority of
nominee

1 x Ceftified that I have no family as defined in para 2(g) of the Employees' Provident Funds Scheme, 1952, and
should I acquire a family hereafter, the above nomination should be deemed as cancelled,
2 x Ceftified that my father/mother is/are dependent upon me.
3. x Strike out whichever is not applicable.

Note: ' A Fresh nomination shall be made by the member on his marriage and any nomination made before such marriage
shall be deemed to be invalid

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PF FORM 02 NEW FORN4AT.doc

 Part B (EPS) (Para 18) $
receive widodchildren pension
I hereby furnish belo particular of the members of my family who would be eligible to
in the event of mY death.

Sl.No. Name and address of the family members Date of Birth Relationship with
the member

(1) (2) (3) (4)

1 RtuUz&n PW"rl L3-qxtc:-"- t I t v-lq L. F",^Ue-r

2 WreB-; l2-8-11' t fy'l o l+\g,Y

3 Se-^ la-tf - l1: El wi 14

4 AAnf rne-^^/n (-o- R.6- l2*139 4 B-xro{^{f
-. Certified that I have no family, as defined in para 2(vii) of Employees' Pension Scheme, 1995 and should I acquire a
family hereafter I shall furnish particulars thereon in the above form.
(i) and (ii)
I hereby nominate the following persons for receiving the monthly widow pension (admissible under para 16 2(a)
of Emolovees'Pension Scheme, 1995 in the event of my death without leaving any eligible family member for receiving
-ffi
eension.

Name and Address of the Nominee Date of Birth Relationship with the member

(1) (21 (3)

Ril^rA^^ p$r"S-r.d t2.-8-1963 Fat-M-r

N:tr..rFs*^^ fl1 ^ fl- 199\\, 1^Ll'0{P

Datedthe: f o,06'2J| 9 I ltllt+

ln. o,F C*,\
v,(Y..
Signature or thumb imPression
of the subscriber
**Strike out whichever is not applicable.

CERTIFICATE BY EMPLOYER
Certified that the above declaration and nomination has been signed/thumb impressed before me by
Shri/Smt./Kumari employed in my establishment
after heishe has read the entnes/the errtries have been read over to him/her by me and got conflrmed by him/her.

Place:
Dated the

Signature of the Employer or other authorised

Officer of the establishment
Designation..
Name and address of the Factory/Establishment
or rubber stamP thereof

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PF FORM 02 NEW FORMAT.doc